1
Clinical Safety amp EffectivenessCohort 4-UTHSCSA
MRI Contrast Mis-administrations
May 21 2010
2
3
The Teambull UTHSCSAUHS
ndash Ken Kist MD (cohort member)
ndash Gilbert Cortez (cohort member)
ndash Kristi Hill-Herrera (cohort member)
ndash Ernest Prince (Patient Care Coordinator UH Radiology)
ndash Abelardo Gonzalez (MRI Technologist UH Radiology)
ndash Jacqueline Young (Customer Service Rep UH Radiology)
ndash UH MRI Technologists and Nurses
bull Sponsor Departmentndash Pam Otto MD
ndash Michelle Ryerson DNP RN
4
AIM Statement
Reduce MRI contrast mis-administrations at University Hospital from 3 in 2009 to 0 (zero) by May 21 2010 maintaining this goal into the future
How is this Project Different
bull Some problems occur in on-going processes and lend themselves to incremental improvements to provide better outcomes to save money or to allow better work flow
bull Other problems have consequences that are so severe that unique processes are required to prevent those problems from ever occurring
bull The goal is to design and implement a process that prevents the problem ie makes it a
bull NEVER EVENT
ROOT CAUSE ANALYSIS
bull The Root Cause is the fundamental underlying reason for a problem which causes it to happen repeatedly
bull If you donrsquot identify the root cause the problem will probably happen again and again
bull Root cause analysis is especially appropriate when dealing with an event that is rare but may have dire consequences
bull Our project focused on the root cause(s) of this type of problem
MRI
bull MRI is an important tool in medicinersquos diagnostic repertoire
bull Last year we performed thousands of MRIrsquos at this institution for multiple indications
bull MRI has unique and powerful imaging capabilities but the strong magnetic field that allows generation of itrsquos images has well known dangers
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
2
3
The Teambull UTHSCSAUHS
ndash Ken Kist MD (cohort member)
ndash Gilbert Cortez (cohort member)
ndash Kristi Hill-Herrera (cohort member)
ndash Ernest Prince (Patient Care Coordinator UH Radiology)
ndash Abelardo Gonzalez (MRI Technologist UH Radiology)
ndash Jacqueline Young (Customer Service Rep UH Radiology)
ndash UH MRI Technologists and Nurses
bull Sponsor Departmentndash Pam Otto MD
ndash Michelle Ryerson DNP RN
4
AIM Statement
Reduce MRI contrast mis-administrations at University Hospital from 3 in 2009 to 0 (zero) by May 21 2010 maintaining this goal into the future
How is this Project Different
bull Some problems occur in on-going processes and lend themselves to incremental improvements to provide better outcomes to save money or to allow better work flow
bull Other problems have consequences that are so severe that unique processes are required to prevent those problems from ever occurring
bull The goal is to design and implement a process that prevents the problem ie makes it a
bull NEVER EVENT
ROOT CAUSE ANALYSIS
bull The Root Cause is the fundamental underlying reason for a problem which causes it to happen repeatedly
bull If you donrsquot identify the root cause the problem will probably happen again and again
bull Root cause analysis is especially appropriate when dealing with an event that is rare but may have dire consequences
bull Our project focused on the root cause(s) of this type of problem
MRI
bull MRI is an important tool in medicinersquos diagnostic repertoire
bull Last year we performed thousands of MRIrsquos at this institution for multiple indications
bull MRI has unique and powerful imaging capabilities but the strong magnetic field that allows generation of itrsquos images has well known dangers
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
3
The Teambull UTHSCSAUHS
ndash Ken Kist MD (cohort member)
ndash Gilbert Cortez (cohort member)
ndash Kristi Hill-Herrera (cohort member)
ndash Ernest Prince (Patient Care Coordinator UH Radiology)
ndash Abelardo Gonzalez (MRI Technologist UH Radiology)
ndash Jacqueline Young (Customer Service Rep UH Radiology)
ndash UH MRI Technologists and Nurses
bull Sponsor Departmentndash Pam Otto MD
ndash Michelle Ryerson DNP RN
4
AIM Statement
Reduce MRI contrast mis-administrations at University Hospital from 3 in 2009 to 0 (zero) by May 21 2010 maintaining this goal into the future
How is this Project Different
bull Some problems occur in on-going processes and lend themselves to incremental improvements to provide better outcomes to save money or to allow better work flow
bull Other problems have consequences that are so severe that unique processes are required to prevent those problems from ever occurring
bull The goal is to design and implement a process that prevents the problem ie makes it a
bull NEVER EVENT
ROOT CAUSE ANALYSIS
bull The Root Cause is the fundamental underlying reason for a problem which causes it to happen repeatedly
bull If you donrsquot identify the root cause the problem will probably happen again and again
bull Root cause analysis is especially appropriate when dealing with an event that is rare but may have dire consequences
bull Our project focused on the root cause(s) of this type of problem
MRI
bull MRI is an important tool in medicinersquos diagnostic repertoire
bull Last year we performed thousands of MRIrsquos at this institution for multiple indications
bull MRI has unique and powerful imaging capabilities but the strong magnetic field that allows generation of itrsquos images has well known dangers
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
4
AIM Statement
Reduce MRI contrast mis-administrations at University Hospital from 3 in 2009 to 0 (zero) by May 21 2010 maintaining this goal into the future
How is this Project Different
bull Some problems occur in on-going processes and lend themselves to incremental improvements to provide better outcomes to save money or to allow better work flow
bull Other problems have consequences that are so severe that unique processes are required to prevent those problems from ever occurring
bull The goal is to design and implement a process that prevents the problem ie makes it a
bull NEVER EVENT
ROOT CAUSE ANALYSIS
bull The Root Cause is the fundamental underlying reason for a problem which causes it to happen repeatedly
bull If you donrsquot identify the root cause the problem will probably happen again and again
bull Root cause analysis is especially appropriate when dealing with an event that is rare but may have dire consequences
bull Our project focused on the root cause(s) of this type of problem
MRI
bull MRI is an important tool in medicinersquos diagnostic repertoire
bull Last year we performed thousands of MRIrsquos at this institution for multiple indications
bull MRI has unique and powerful imaging capabilities but the strong magnetic field that allows generation of itrsquos images has well known dangers
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
How is this Project Different
bull Some problems occur in on-going processes and lend themselves to incremental improvements to provide better outcomes to save money or to allow better work flow
bull Other problems have consequences that are so severe that unique processes are required to prevent those problems from ever occurring
bull The goal is to design and implement a process that prevents the problem ie makes it a
bull NEVER EVENT
ROOT CAUSE ANALYSIS
bull The Root Cause is the fundamental underlying reason for a problem which causes it to happen repeatedly
bull If you donrsquot identify the root cause the problem will probably happen again and again
bull Root cause analysis is especially appropriate when dealing with an event that is rare but may have dire consequences
bull Our project focused on the root cause(s) of this type of problem
MRI
bull MRI is an important tool in medicinersquos diagnostic repertoire
bull Last year we performed thousands of MRIrsquos at this institution for multiple indications
bull MRI has unique and powerful imaging capabilities but the strong magnetic field that allows generation of itrsquos images has well known dangers
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
ROOT CAUSE ANALYSIS
bull The Root Cause is the fundamental underlying reason for a problem which causes it to happen repeatedly
bull If you donrsquot identify the root cause the problem will probably happen again and again
bull Root cause analysis is especially appropriate when dealing with an event that is rare but may have dire consequences
bull Our project focused on the root cause(s) of this type of problem
MRI
bull MRI is an important tool in medicinersquos diagnostic repertoire
bull Last year we performed thousands of MRIrsquos at this institution for multiple indications
bull MRI has unique and powerful imaging capabilities but the strong magnetic field that allows generation of itrsquos images has well known dangers
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
MRI
bull MRI is an important tool in medicinersquos diagnostic repertoire
bull Last year we performed thousands of MRIrsquos at this institution for multiple indications
bull MRI has unique and powerful imaging capabilities but the strong magnetic field that allows generation of itrsquos images has well known dangers
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
We knowthings can go wrong in the MRI suite
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
Gadolinium Based Contrast Agents
bull We perform hundreds of MRIrsquos every year with contrast enhancement
bull In institutions like ours many of these MRIrsquos are performed on patients with multiple disease processes
bull The suitability and safety of MRI as a diagnostic test for one process can be effected by these co-morbidities
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is a rare (~5 cases1000 patient-years) syndrome characterized by thickening and tightening of the skin and subcutaneous tissues which can involve skeletal muscles myocardium lungs liver and other solid organs
bull NSF is debilitating frequently progressive and has no effective treatment It does not spontaneously resolve and can contribute to or cause early patient demise
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
NSF(Nephrogenic Systemic Fibrosis)
bull The syndrome was first described in 1997 and many trigger etiologies have been proposed (hypercoagulation syndromes anti-phospholipid antibodies deep vein thrombosis metabolic acidosis erythropoietin administration and surgical or vascular interventions)
bull But in the early and mid years of the last decade one particular association became very clear
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
NSF(Nephrogenic Systemic Fibrosis)
bull NSF is associated with the administration of Gadolinium based contrast agents used for MRI
bull Andbull The syndrome occurred in a select group of patients
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
NSF(Nephrogenic Systemic Fibrosis
bull NSF is associated with the administration of gadolinium based contrast agents in patients with
bull Acute renal failure
bull Severe chronic renal failure
bull Patients in the perioperative period of liver or renal transplant
bull But it probably only occurs in 2-4 of this population
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
bull We thought gad was really safe and in fact often used contrast enhanced MRI as an alternative to Iodine enhanced CT scans in patients with poor renal function
bull We thought This shouldnrsquot be too much of a problem Wersquoll just never give gadolinium to patients with low GFR or in the peritransplant period
bull But sometimes things can go wrong
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
Goal
bull Our challenge was to develop a system that made the accidental administration of gadolinium based contrast agents to inappropriate candidates nearly impossible
bull We must prevent this from happeninghellip
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
Goal
bull And as an additional incentive we must avoid this consequencehellip
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
30
Project Milestones
bull Team Created December 2009
bull AIM statement created January 2010
bull Weekly Team Meetings January-April 2010
bull Background Data Brainstorm Sessions January-February 2010
bull Workflow and Fishbone Analyses January-February 2010
bull Interventions Implemented January-March 2010
bull Data Analysis March-May 2010
bull CSampE Presentation May 2010
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
31
Selected Process Analysis Tools
bull Brainstorming
bull Fish Bone
bull Flow Chart
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
32
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
33
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
34
How Will We Know That a Change is an Improvement
bull There will be no new events
bull There are no new problems created because of a change
bull G-Chart (time between rare events)
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
35
What Changes Can We Make That Will Result in an Improvement
bull Establish a specific process based on established criteria for screening patients
bull Create a work-flow that allows for a double-check process between two technologists or a technologist and a nurse- the final stopbarrier
bull Reduce distractions for the technologists
bull Raise awareness level to a degree that all staff realize the importance and treat this a never-event
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
36
Intervention
middotImplement a final time out process
middotReduce distractions
middotContinue to identify failure points in the process
Plan
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
37
Implementing the Change
Do
middotJanuary 25 2010-Implemented the time-out process with two staff members-nurse and technologist or two technologists
middotBy day 3 we had 100 compliance from all shifts
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
38
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
Implementing the Change
Do
January ndashFebruary
middotRaised the awareness level of all staff on the distractions in the environment Worked to reduce these with verbal and visual queues
39
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
40
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
ResultsImpact
Check
bull Time out forms were audited for continued compliance
bull Held meetings with staff for input on the new process
bull G chart selected as the tool most appropriate to measure time between rare events As of May 21 2010 we are at 205 days since the last event
41
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
42
ResultsImpact
34310
854000
0
50
100
150
200
250
300
350
400
Day
s bet
wee
n E
ven
ts
Date
Days between Events
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
Expansion of Our Implementation
Act
middotChanges showed positive progress and were continued with input from the staff
middotThe time-out steps have become a natural part of the workflow
middotDistractions have been reduced as seen by observations and staff input Will continue to monitored by all
middotThe work-flow process continues to be monitored43
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
Applicability
bull This same process can be applied to iodinated contrast in CT
bull Distractions are an issue in all modalities Efforts toward reducing these and empowering staff to limit unnecessary interruptions will be broadened
44
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
Umar Farouk Abdulmuttalab
bull On Christmas 2009 in spite of world-wide efforts to prevent airplane bombings this 23 year old got on a plane with plastic explosives in his underpants and tried to blow up the plane over Detroit
bull No system of prevention is perfect
bull Our current protocols are always being re-evaluated to detect flaws and deficiencies that could let a mis-administration get by
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
47
ConclusionWhatrsquos Next
Staff have learned the time-out process and it appears to have become a part of the culture Will continue to spot check and make observations
Reducing distractions is difficult unless staff is willing to intervene with others at crucial points Will monitor by making observations and asking all staff to participate in this monitoring- ldquohave each otherrsquos backsrdquo
Evaluate the new work environment as the MRI suite moves in 2010
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
References
bull Nephrogenic Systemic Fibrosis A Population Study Examining the Relationship of Disease Development to Gadolinium Exposure
bull Aneet Deo Mitchell Fogel and Shawn E Cowper
bull Clin J Am Soc Nephrol 2 264-267 2007copy 2007 American Society of Nephrologydoi 102215CJN03921106
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
bull MR imaging in patients at risk for developing nephrogenic systemic fibrosis protocols practices and imaging techniques to maximize patient safety
bull Juluru K Vogel-Claussen J Macura KJ Kamel IR Steever A Bluemke DA
bull Radiographics 2009 Nov29(7)2099
bull PMID 19019996
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
bull Nephrogenic systemic fibrosis incidence associations and effect of risk factor assessment--report of 33 cases
bull Radiology 2009 Feb250(2)371-7
bull Perez-Rodriguez J Lai S Ehst BD Fine DM Bluemke DA
bull PMID 19188312
51
Thank you
51
Thank you
Top Related